Guidelines on radiographic imaging as part of root canal treatment: a systematic review with a focus on review imaging after treatment.

AIM: To identify guidelines on endodontics which make recommendations relating to post-root canal treatment radiological review imaging, to make an objective assessment of their quality using the AGREE tool and to examine the evidence cited in support of their recommendations. METHODOLOGY: The primary sources to identify published guidelines were MEDLINE (Ovid® ) and EMBASE. The search aim was to identify guidelines pertaining to the post-root canal treatment follow-up recommendations published from 1946 with the final search date being 26 June 2016. The primary search was supplemented by searching Internet search engines and several websites that might have guidelines. The guidelines obtained from the search end-result were assessed for quality and scientific evidence using the AGREE II instrument. Similarities and differences in the recommendations were identified. RESULTS: Thirty guidelines were identified, seven of which met the inclusion criteria. Two guidelines used and clearly described the methods for obtaining scientific evidence from which the recommendations were set. The recommendations varied, particularly as regards the timing of the first review radiograph. Some guidelines lacked supporting evidence. CONCLUSIONS: The recommendations for post-root canal treatment radiographic follow-up varied amongst the identified guidelines. However, the methodology for obtaining the scientific evidence was poorly described in most of the guidelines. Guideline development groups should use the AGREE II instrument as a guide to produce higher quality guidelines.

The impact of premature birth on the mandibular cortical bone of children.

SUMMARY: Children born prematurely often have reduced skeletal mineralization. The aim in this study was to compare the cortical thickness of the lower jaw on radiographs of 8- to 10-year-old children with histories of preterm or full term births. There were no significant differences in cortical thickness between full term and preterm children at this age. INTRODUCTION: The purpose of this study was to compare the cortical thickness of the mandible on panoramic radiographs of 8- to 10-year-old children with histories of preterm or full term births. METHODS: Panoramic radiography was performed on 36 extremely preterm, 38 very preterm and 42 full term children at the age of 8 to 10 years. Five observers independently measured the mandibular cortical width on the panoramic radiographs at four defined sites bilaterally. Altogether, 928 sites were available. Measurements were performed twice on a random 24% of the sites by four observers. One-way analysis of variance with Tukey's post hoc test was used to test differences between groups. Intraclass correlation coefficient (ICC) was calculated for interobserver agreement while intra-observer agreement was expressed as measurement precision. RESULTS: Significant differences of mandibular cortical width were found between extremely preterm and very preterm children for five of the eight measurement sites with the very preterm showing the highest value. No significant differences were found between full term and either very preterm or extremely preterm except for one measurement site, with the extremely preterm showing the lowest value. ICC varied between 0.30 and 0.83 for the different sites (mean 0.62). The precision of a single measurement varied between 0.11 and 0.45 mm (mean 0.25 mm). CONCLUSIONS: From the evidence that very preterm children had significantly thicker mandibular cortices than extremely preterm children, we suggest that these findings may reflect the effect of mineral supplementation provided to premature infants, causing a 'shifting up' of bone mineral status relative to the full term peer group while maintaining the difference between very preterm and extremely preterm born children.

Do patients with osteoporosis have an increased prevalence of periodontal disease? A cross-sectional study.

UNLABELLED: The study examined if women with osteoporosis were at increased risk of periodontal disease. Three hundred eighty females aged 45-65 years with recent dual-energy X-ray absorptiometry (DXA) scans of the spine and proximal femur agreed to a dental examination. No association was established between the presence of severe periodontal disease and osteoporosis. INTRODUCTION: The purpose of this study is to determine whether patients with osteoporosis have an increased severity and extent of periodontal disease, taking full account of confounding factors. METHODS: Volunteer dentate women (45-65 years), who had undergone recent DXA of the femur and lumbar spine, received a clinical examination of their periodontal tissues by a single trained operator who was blind to the subject's osteoporosis status. Clinical examinations were performed within 6 months of the DXA. Basic Periodontal Examination score, gingival bleeding score, periodontal pocket depth, recession and calculus were the periodontal outcome measures. Potential confounding factors were recorded. Logistic regression was performed for the dichotomous outcome measure of severe periodontal disease (present or absent) with osteoporotic status, adjusting for confounding factors. RESULTS: There were 380 dentate participants for whom DXA data were available. Of these, 98 had osteoporosis. When compared with osteoporotic subjects, those with normal bone mineral density were significantly younger (p = 0.01), had a higher body mass index (p = 0.03) and had more teeth (p = 0.01). The prevalence of severe periodontal disease in the sample was 39 %. The unadjusted odds ratio for the association between osteoporosis and severe periodontal disease was 1.21 (0.76 to 1.93). The adjusted odds ratio analysis including other covariates (age, smoking, hormone replacement therapy, alcohol) was 0.99 (0.61 to 1.61). CONCLUSION: No association was established between the presence of severe periodontal disease and osteoporosis.

Leishmania major inhibits IL-12 in macrophages by signalling through CR3 (CD11b/CD18) and down-regulation of ETS-mediated transcription.

Leishmania major is an aetiological agent of cutaneous leishmaniasis. The parasite primarily infects immune sentinel cells, specifically macrophages and dendritic cells, in the mammalian host. Infection is receptor mediated and is known to involve parasite binding to cell surface protein complement receptor 3 (CR3, Mac-1, CD11b/CD18). Engagement of CR3 by various ligands inhibits production of interleukin-12 (IL-12), the cytokine that drives antileishmanial T helper 1-type immune responses. Likewise, L. major infection inhibits IL-12 production and activation of host macrophages. Our data indicate that in the absence of CR3, L. major-infected bone marrow-derived macrophages produce more IL-12 and nitric oxide compared with WT cells upon lipopolysaccharide (LPS) stimulation. We therefore investigated multiple signalling pathways by which L. major may inhibit IL-12 transcription through CR3 ligation. We demonstrate that L. major infection does not elicit significant NFκB p65, MAPK, IRF-1 or IRF-8 activation in WT or CD11b-deficient macrophages. Furthermore, infection neither inhibits LPS-induced MAPK or NFκB activation nor blocks IFN-γ-activated IRF-1 and IRF-8. ETS-mediated transcription, however, is inhibited by L. major infection independently of CR3. Our data indicate that L. major-mediated inhibition of IL-12 occurs through CR3 engagement; however, the mechanism of inhibition is independent of NFκB, MAPK, IRF and ETS.

The relationship between osteoporosis and periodontitis in women aged 45-70 years.

OBJECTIVE: To explore the possible relationship between the osteoporotic condition and the severity of periodontitis in women aged 45-70 years. MATERIALS AND METHODS: Ninety women with generalized chronic periodontitis, aged 45-70 years, were studied. Areal bone mineral density (BMDa) was assessed using standardized dual energy X-ray absorptiometry (normal: T-score ≥ -1, osteopenic: -2.5 ≤ T-score <-1, osteoporotic: T-score < -2.5). Gingival index (GI), bleeding on probing, clinical attachment loss (CAL), probing pocket depth and gingival recession (GR) were recorded. Periodontitis severity was represented by CAL. Menopausal condition and smoking were documented. RESULTS: Mean GI, bleeding on probing, CAL and GR were significantly greater for osteoporotic women than women with normal BMDa (P = 0.002, P = 0.01, P = 0.04, respectively). Osteopenic women and women with normal BMDa significantly differed in mean GI (P = 0.02). The associations found between osteoporotic women and women with normal BMDa and the associations found between osteopenic women and women with normal BMDa existed even after adjusting for smoking and menopausal status. CONCLUSION: Subjects with osteoporosis (OPR) presented with greater CAL than the subjects with normal BMDa, which suggests a greater severity of periodontitis. Subjects with OPR had greater GR than the subjects with normal BMDa. Subjects with osteopenia and subjects with normal BMDa did not differ in CAL, which might suggest that the early diagnosis of reduced BMDa, prior to the establishment of a significant negative impact on the periodontal tissues, might be important. Smoking and menopausal status did not alter these associations.

Exercise, appetite and weight management: understanding the compensatory responses in eating behaviour and how they contribute to variability in exercise-induced weight loss.

Does exercise promote weight loss? One of the key problems with studies assessing the efficacy of exercise as a method of weight management and obesity is that mean data are presented and the individual variability in response is overlooked. Recent data have highlighted the need to demonstrate and characterise the individual variability in response to exercise. Do people who exercise compensate for the increase in energy expenditure via compensatory increases in hunger and food intake? The authors address the physiological, psychological and behavioural factors potentially involved in the relationship between exercise and appetite, and identify the research questions that remain unanswered. A negative consequence of the phenomena of individual variability and compensatory responses has been the focus on those who lose little weight in response to exercise; this has been used unreasonably as evidence to suggest that exercise is a futile method of controlling weight and managing obesity. Most of the evidence suggests that exercise is useful for improving body composition and health. For example, when exercise-induced mean weight loss is <1.0 kg, significant improvements in aerobic capacity (+6.3 ml/kg/min), systolic (-6.00 mm Hg) and diastolic (-3.9 mm Hg) blood pressure, waist circumference (-3.7 cm) and positive mood still occur. However, people will vary in their responses to exercise; understanding and characterising this variability will help tailor weight loss strategies to suit individuals.

The diagnostic efficacy of cone beam CT for impacted teeth and associated features: a systematic review.

This review evaluates the evidence for the diagnostic efficacy of cone beam computed tomography (CBCT) for impacted teeth and associated features. PubMed, Embase and the Cochrane Library were searched using specific indexing terms and reference lists were hand searched. Two reviewers selected relevant publications on the basis of pre-determined inclusion criteria. Original studies were assessed using a modification of the quality assessment of diagnostic accuracy studies (QUADAS) tool. The literature search yielded 96 titles, of which 7 were included in the review. There was only limited evidence for diagnostic efficacy expressed as sensitivity, specificity and predictive values. Only two studies compared CBCT and panoramic radiographs with a valid reference method and presented the results in terms of percentage of correct diagnoses. This review reveals a need for studies that meet methodological standards for diagnostic efficacy of CBCT in the diagnosis of impacted teeth.

The use of localised CBCT to image inflammatory collateral cysts: a retrospective case series demonstrating clinical and radiographic features.

INTRODUCTION: Inflammatory collateral cysts are uncommon cysts primarily affecting first permanent molars during their eruption. There are diagnostic challenges that can be overcome with CBCT imaging. However, given the paediatric age group for this condition, there are patient cooperation and radiation dose factors to consider when justifying the scan. The aim of this case series study is to illustrate the value of CBCT in imaging and diagnosing inflammatory collateral cysts in paediatric patients, to highlight the need for a multidisciplinary approach for this uncommon pathological condition and to review the relevant literature. CASE SERIES DESCRIPTION AND RESULTS: We present three patients aged between 6 and 11 years of age with inflammatory collateral cysts affecting their first or second permanent molars for which CBCT imaging was utilised. All patients underwent cyst enucleation with preservation or extraction of affected teeth under general anaesthesia. DISCUSSION: Inflammatory collateral cysts are likely to be under reported given their indistinct clinical features and radiological signs. Conventional planar radiographs may not reveal this lesions size and full extent. CBCT overcomes these limitations; however, careful assessment of patient cooperation is needed and a low-dose protocol should be used. CONCLUSIONS: CBCT can provide useful imaging information which is difficult to obtain using conventional radiography, especially in cases where an inflammatory collateral cyst is suspected.

Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review.

PURPOSE: To determine in which clinical situations it is indicated or contra-indicated to prescribe cone beam computed tomography (CBCT) for paediatric patients. METHODS: Systematic review of in vivo paediatric research studies of diagnostic efficacy using CBCT, with supplementary searches for guideline documents on CBCT and for systematic reviews permitting inclusion of ex vivo and adult studies. RESULTS: After screening, 190 publications were included, mostly case studies. No systematic reviews were found of in vivo paediatric research. Fourteen studies of diagnostic efficacy were identified. The supplementary searches found 18 guideline documents relevant to the review and 26 systematic reviews. The diagnostic efficacy evidence on CBCT was diverse and often of limited quality. There was ex vivo evidence for diagnostic accuracy being greater using CBCT than radiographs for root fractures. The multiplanar capabilities of CBCT are advantageous when localising dental structures for surgical planning. Patient movement during scanning is more common in children which could reduce diagnostic efficacy. CONCLUSIONS: No strong recommendations on CBCT are possible, except that it should not be used as a primary diagnostic tool for caries. Guidelines on use of CBCT in the paediatric age group should be developed cautiously, taking into account the greater radiation risk and the higher economic costs compared with radiography. CBCT should only be used when adequate conventional radiographic examination has not answered the question for which imaging was required. Clinical research in paediatric patients is required at the higher levels of diagnostic efficacy of CBCT.

Correction to: Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review.

In the original publication of the article the fifth author's name "A. Littlewood" was submitted as "A. Littewood" which was left unnoticed in the later stages. The correct name is as published in this erratum.

Best clinical practice guidance for prescribing dental radiographs in children and adolescents: an EAPD policy document.

BACKGROUND: The European Academy of Paediatric Dentistry (EAPD) proposes this best clinical practice guidance to help practitioners decide when and how to prescribe dental radiographs in children and adolescents. METHODS: Four expert working groups conducted each a systematic review of the literature. The main subjects were radiation protection, intraoral dental radiography (bitewing and periapical radiographs), panoramic radiography (PR) and cone-beam computed tomography (CBCT). In addition, three workshops were held during the corresponding EAPD Interim Seminar in Chania (Crete, Greece) in 2019. On the basis of the identified evidence, all invited experts presented their findings and during the workshops aspects of clinical relevance were discussed. RESULTS: Several clinical-based recommendations and statements were agreed upon. CONCLUSION: There is no or low-grade evidence about the efficacy of dental radiographic examinations in young populations. The given recommendations and rationales should be understood as best clinical practice guidance. It is essential to respect the radiological principles of an individualized and patient-specific justification. When a dental radiograph is required, its application needs to be optimized, aiming at limiting the patient's exposure to ionising radiation according to the ALADAIP principle (As Low As Diagnostically Achievable being Indication-oriented and Patient-specific).

The detection and management of root resorption lesions using intraoral radiography and cone beam computed tomography - an in vivo investigation.

AIM: To compare the accuracy of intraoral periapical radiography with cone beam computed tomography (CBCT) for the detection and management of resorption lesions. METHODOLOGY: Digital intraoral radiographs and CBCT scans were taken of patients with internal resorption (n = 5), external cervical resorption (n = 5) and no resorption (controls) (n = 5). A 'reference standard' diagnosis and treatment plan was devised for each tooth. Sensitivity, specificity, positive predictive values, negative predictive values and receiver operator characteristic (ROC) curves, as well as the reproducibility of each technique were determined for diagnostic accuracy and treatment option chosen. RESULTS: The intraoral radiography ROC Az values were 0.780 and 0.830 for diagnostic accuracy of internal and external cervical resorption respectively. The CBCT ROC Az values were 1.000 for both internal and external cervical resorption. There was a significantly higher prevalence (P = 0.028) for the correct treatment option being chosen with CBCT (%) compared with intraoral radiographs (%). CONCLUSION: CBCT was effective and reliable in detecting the presence of resorption lesions. Although digital intraoral radiography resulted in an acceptable level of accuracy, the superior accuracy of CBCT may result in a review of the radiographic techniques used for assessing the type of resorption lesion present. CBCT's superior diagnostic accuracy also resulted in an increased likelihood of correct management of resorption lesions.

Observer performance in diagnosing osteoporosis by dental panoramic radiographs: results from the osteoporosis screening project in dentistry (OSPD).

Mandibular cortical erosion detected on dental panoramic radiographs (DPRs) may be useful for identifying women with osteoporosis, but little is known about the variation in diagnostic efficacy of observers worldwide. The purpose of this study was to measure the accuracy in identifying women at risk for osteoporosis in a worldwide group of observers using DPRs. We constructed a website that included background information about osteoporosis screening and instructions regarding the interpretation of mandibular cortical erosion. DPRs of 100 Japanese postmenopausal women aged 50 years or older who had completed skeletal bone mineral measurements by dual energy X-ray absorptiometry were digitized at 300 dpi. These were displayed on the website and used for the evaluation of diagnostic efficacy. Sixty observers aged 25 to 66 years recruited from 16 countries participated in this study. These observers classified cortical erosion into one of three groups (none, mild to moderate, and severe) on the website via the Internet, twice with an approximately 2-week interval. The diagnostic efficacy of the Osteoporosis Self-Assessment Tool (OST), a simple clinical decision rule based on age and weight, was also calculated and compared with that of cortical erosion. The overall mean sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the 60 observers in identifying women with osteoporosis by cortical erosion on DPRs were 82.5, 46.2, 46.7, and 84.0%, respectively. Those same values by the OST index were 82.9, 43.1, 43.9, and 82.4%, respectively. The intra-observer agreement in classifying cortical erosion on DPRs was sufficient (weighted kappa values>0.6) in 36 (60%) observers. This was significantly increased in observers who specialized in oral radiology (P<0.05). In the 36 observers with sufficient intra-observer agreement, the overall mean sensitivity, specificity, PPV, and NPV in identifying women with osteoporosis by any cortical erosion were 83.5, 48.7, 48.3, and 85.7%, respectively. The mean PPV and NPV were significantly higher in the 36 observers with sufficient intra-observer agreement than in the 24 observers with insufficient intra-observer agreement. Our results reconfirm the efficacy of cortical erosion findings in identifying postmenopausal women at risk for osteoporosis, among observers with sufficient intra-observer agreement. Information gathered from radiographic examination is at least as useful as that gathered from the OST index.

Detecting the earliest radiological signs of bisphosphonate-related osteonecrosis.

Introduction Oral bisphosphonates are the most commonly prescribed anti-resorptive drugs used in the treatment of osteoporosis, but osteonecrosis of the jaw is a serious complication. The early diagnosis of this destructive side effect is crucial in preventing excessive bone loss, pain and infection.Objective To aid dental practitioners in the early identification of bisphosphonate-related osteonecrosis of the jaw.Method A scoping review was carried out.Data sources We searched MEDLINE via OVID, EMBASE via OVID, Dentistry and Oral Sciences Source (DOSS), Proquest Dissertation and Theses Search, to identify references that described clinical and radiological findings in medication-related osteonecrosis of the jaw (MRONJ).Data selection Nineteen references mentioned the earliest radiological changes in MRONJ with a description of the observations and were included in the analysis.Data synthesis The radiographic signs included osteosclerosis/lysis, widening of the periodontal ligament and thickening of the lamina dura and cortex. To assess the quality of original data on which recommendations had been made, these 19 studies were subjected to a quality appraisal.Conclusion Using bone exposure as a criterion for diagnosis of MRONJ, leads to delayed diagnosis and a poor response to treatment. In those patients at risk of bone exposure with MRONJ, insufficient information is present in the literature to allow the general dental practitioner to reliably identify the radiographic features indicating imminent bone exposure. A well-designed prospective study is needed.

Accuracy in osteoporosis diagnosis of a combination of mandibular cortical width measurement on dental panoramic radiographs and a clinical risk index (OSIRIS): the OSTEODENT project.

Clinical questionnaires and dental radiographic findings have both been suggested as methods of identifying women at risk of having osteoporosis and who might benefit from bone densitometry. The aim of this study was to measure the diagnostic accuracy of a combination of mandibular cortical width (MCW) measured from dental panoramic radiographs (DPRs) and the osteoporosis index of risk (OSIRIS) in the diagnosis of osteoporosis. 653 women (age range 45-70 years, mean age 54.95 years) in four European centres underwent standardised dual X-ray energy absorptiometry (DXA) to provide reference data on osteoporosis status. Each subject was interviewed to derive OSIRIS scores and underwent DPR examination. MCW was measured directly by five observers. Receiver Operating Characteristic (ROC) curve analysis was used to calculate sensitivities and specificities of the clinical and radiographic tests for the diagnosis of osteoporosis. 512 (78.4%) of the study population were classified as having normal BMD and 141 (21.6%) as having osteoporosis. Using ROC analysis, OSIRIS gave a ROC curve area (A(z)) of 0.838, with a sensitivity of 70.9% and a specificity of 79.5% at a diagnostic threshold of

Automated osteoporosis risk assessment by dentists: a new pathway to diagnosis.

General dental practitioners use a vast amount of panoramic radiography in their routine clinical work, but valuable information about patients' osteoporotic status is not collected. There are many reasons for this, but one of the prime reasons must be the disruption involved in clinical routine with lengthy manual radiographic assessment. We have developed computer software, based on active shape modeling that will automatically detect the mandibular cortex on panoramic radiographs, and then measure its width. Automatic or semi-automatic measurement of the cortical width will indicate the osteoporotic risk of the patient. The aim of our work was to assess the computer search technique's ability to measure the mandibular cortical width and to assess its potential for detection of osteoporosis of the hip, spine and femoral neck. Mandibular cortical width was measured using the manually initialized (semi-automatic) method and, when assessed for diagnosing osteoporosis at one of the three measurement sites, gave an area under the ROC curve (A(z))=0.816 (95% CI=0.784 to 0.845) and for the automatically initialized searches, A(z)=0.759 (95% CI=0.724 to 0.791). The difference between areas=0.057 (95% Confidence interval=0.025 to 0.089), p<0.0001. For diagnosing osteoporosis at the femoral neck, mandibular cortical width derived from the manually initialized fit gave an area under the ROC curve (A(z))=0.835 (95% CI=0.805 to 0.863) and for the automatically initialized searches A(z)=0.805 (95% CI=0.773 to 0.835). The difference in A(z) values between active shape modeling search methods=0.030 (95% CI=-0.010 to 0.070), and this was not significant, p=0.138. We concluded that measurement of mandibular cortical width using active shape modeling is capable of diagnosing skeletal osteoporosis with good diagnostic ability and repeatability.

Prediction of bone mineral density with dental radiographs.

There is consensus to use the bone mineral density (BMD) for the operational definition of the degree of osteoporosis and the risk of osteoporotic fractures. Dual X-ray absorptiometry (DXA) is the common technique to determine BMD. Because of high costs and limited availability of DXA equipment it is worthwhile to look for alternative diagnostic techniques. As part of a larger study, the Osteodent project, we investigated if the trabecular pattern on dental radiographs can be used to predict BMD and to identify the subjects with osteoporosis and increased risk of osteoporotic fractures. In four clinical centers 671 women with an average age of 55 years were recruited. BMD values were measured by DXA equipment at the femoral neck, total hip, and spine. One panoramic and two intraoral radiographs were made. From 525 women a complete set of BMD values and radiographs was obtained. Four regions of interest on the radiographs were selected manually and then processed automatically. On all regions of interest mean and standard deviation of the gray values were measured and several features describing the shape of the binarized trabecular pattern. Multiple regression was used to predict BMD of total hip and spine by means of the radiographic measurements combined with age. It was found that age accounts for 10% of the variation in total hip BMD and 14% of the variation in spinal BMD. When all measurements on the dental radiographs are used the explained variation increases to 22% and 23%. The areas under the ROC curves are comparable to those of commonly used screening instruments for osteoporosis. It is concluded that prediction of DXA measurements of BMD by means of quantitative analysis of the trabecular pattern on dental radiographs is feasible.

Dental diagnostic radiology in the forensic sciences: two case presentations.

Dentomaxillofacial radiology is a useful tool in forensic science to reveal characteristics of the structures of the dentomaxillofacial region. Postmortem radiographs are valuable to the forensic odontologist for comparison with antemortem radiographs, which are the most consistent part of the antemortem records that can be transmitted during forensic examination procedures. By using dentomaxillofacial radiology we can, therefore, give answers to problems dealing with identification cases, mass disasters and dental age estimation. We present the contribution of dentomaxillofacial radiology to the forensic sciences through two cases of deceased persons, where identification was based on information provided by radiographs. The right performance, interpretation and reportage of dentomaxillofacial radiological examination and procedures can be extremely valuable in solving forensic problems.